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Milk, coronary heart disease and mortality
A R Ness, G Davey Smith and C Hart
J. Epidemiol. Community Health 2001;55;379-382
doi:10.1136/jech.55.6.379
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J Epidemiol Community Health 2001;55:379–382
379
Milk, coronary heart disease and mortality
A R Ness, G Davey Smith, C Hart
Abstract
Study objective—To study the association
between reported milk consumption and
cardiovascular and all cause mortality.
Design—A prospective study of 5765 men
aged 35–64 at the time of examination.
Setting—Workplaces in the west of Scotland between 1970 and 1973.
Participants—Men who completed a
health and lifestyle questionnaire, which
asked about daily milk consumption, and
who attended for a medical examination.
Main results—150 (2.6%) men reported
drinking more than one and a third pints a
day, Some 2977 (51.6%) reported drinking
between a third and one and a third pints
a day and 2638 (45.8%) reported drinking
less than a third of a pint a day. There were
a total of 2350 deaths over the 25 year follow up period, of which 892 deaths were
attributed to coronary heart disease. The
relative risk, adjusted for socioeconomic
position, health behaviours and health
status for deaths from all causes for men
who drank one third to one and a third
pints a day versus those who drank less
than a third of a pint was 0.90 (95% CI
0.83, 0.97). The adjusted relative risk for
deaths attributed to coronary heart disease for men who drank one third to one
and a third pints a day versus those who
drank less than one third of a pint was 0.92
(95% CI 0.81, 1.06).
Conclusions—No evidence was found that
men who consumed milk each day, at a
time when most milk consumed was full
fat milk, were at increased risk of death
from all causes or death from coronary
heart disease.
(J Epidemiol Community Health 2001;55:379–382)
Department of Social
Medicine, Canynge
Hall, Whiteladies
Road, Bristol
BS8 2PR, UK
A R Ness
G Davey Smith
Department of Public
Health, University of
Glasgow, Glasgow
C Hart
Correspondence to:
Dr Ness
([email protected])
Accepted for publication
14 January 2001
The eVects on population health of increased
intake of milk are uncertain. In the first half of
this century increased milk production and
consumption was encouraged, particularly in
children, as it was believed to improve vitality
and shown to increase growth in children.1
After the second world war the epidemic of
coronary heart disease (CHD) and the accumulating evidence that increased saturated fat
intake, by increasing blood cholesterol levels,
increased risk of coronary disease,2 3 led to a
review of policy. Increasingly, in recent years,
the public has been encouraged both to reduce
their milk intake and to switch to low fat milk
products in order to reduce their fat consumption.4 Recent studies, however, have suggested
that increased fat intake may be protective for
stroke.5
www.jech.com
Ecological analyses have shown high correlations between milk intake and coronary
mortality rates6 7 (which tend to be at least as
strong as those observed for saturated fat). The
focus of many observational studies on dietary
constituents rather than food items means that
the individual based data available on milk and
cardiovascular risk are limited. Given the relative lack of prospective data on the association
between milk intake, CHD and other diseases
we have analysed the association between milk
intake and mortality in a large cohort of men in
the west of Scotland on whom we have detailed
information regarding important potential
confounding factors.
Methods
This analysis is based on a cohort of 5765 men
aged 35–64 at the time of examination
recruited from workplaces in the west of Scotland between 1970 and 1973. Full details of
the present study population (The Collaborative Study) and the data collection methods
have been described previously.8 9
The information collected at baseline included: sociodemographic data, health status
measures, information on health related behaviours and measurements recorded at a physical
examination. Data are available on the subject’s
age, their father’s occupation and their occupation at the time of screening (coded to social
class). Data are also available on the subject’s
age at leaving full time education, their number
of siblings and whether they were regular car
drivers. In addition, the home address at the
time of screening was retrospectively allocated
a postcode, enabling an area-based deprivation
category at the time of the 1981 census to be
ascertained. Deprivation category varies from 1
(least deprived) to 7 (most deprived). Details
of self reported angina from the Rose questionnaire (with angina defined as definite)10 and self
reported respiratory symptoms from the Medical Research Council questionnaire11 are available. Detailed information on smoking and
alcohol consumption12 was recorded. At examination height, weight, blood pressure and lung
function were measured, an electrocardiogram
performed and blood drawn for estimation of
plasma cholesterol and triglycerides. Forced
expiratory volume in one second, FEV1,
expressed as a percentage of the expected FEV1
for age and height, was calculated from the
subset of healthy participants.9
Men were sent a self completed questionnaire. One question asked men how many pints
of milk they usually drank each day. The
answers to this question were checked when
the men attended for screening. The responses
to this question were used to allocate men into
three groups. Men who drank less than a third
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380
Ness, Davey Smith, Hart
Table 1 Age adjusted means and proportions of characteristics according to self reported
milk consumption at baseline
Pints of milk per day (1 pint = 0.568 litres)
Number of men
Age*
Social class I and II (%)
Father’s social class I and II (%)
Regular drivers (%)
Number of siblings
Deprivation category 6 and 7 (%)
Leave education at 14 years or under
Angina (%)
ECG ischaemia (%)
Bronchitis (%)
Never smoker (%)
Current cigarette smoker (%)
Cigarettes per day†
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Cholesterol (mmol/l)
Height (cm)
Body mass index (kg/m2)
Triglycerides (mmol/l)‡
FEV1 score (%)
Units of alcohol per week
none
one
> than one
p value for
trend
2638
49.0
30.7
12.6
49.0
3.5
31.4
53.1
6.6
5.8
2.4
16.9
57.0
19.2
133.9
83.9
5.87
172.2
25.2
1.37
93.5
12.7
2977
47.7
33.9
14.5
54.2
3.4
26.4
49.0
6.0
5.9
2.0
18.1
54.2
18.7
133.9
83.8
5.89
173.4
25.1
1.37
94.8
11.4
150
46.2
31.3
16.3
51.2
3.4
24.6
52.3
1.5
3.7
1.3
23.8
50.8
19.8
136.1
85.0
5.90
173.5
25.5
1.32
98.0
12.1
0.0001
0.009
0.009
0.0004
0.032
0.0001
0.013
0.09
0.77
0.20
0.08
0.020
0.23
0.45
0.68
0.46
0.0001
0.50
0.82
0.002
0.009
*Not age adjusted. †Current smokers only. ‡For 5300 who fasted and were not diabetic.
Health Service Central Registry in Edinburgh,
which also provides death certificates coded
according to the ninth revision of the International Classification of Diseases (ICD).
Continuous variables have been age standardised using PROC GLM, in the SAS system,
with tests for trend for age adjusted means
being obtained through PROC REG. Categorical variables have been age standardised by the
direct method and tests for trend performed in
PROC LOGIST. Proportional hazards coeYcients and their standard errors were calculated
using PROC PHREG with adjustment for age
and other risk factors by including terms for
these in the proportional hazards models.
Exponentiated hazards coeYcients are taken as
indicators of relative rates of mortality. For
missing values of variables a dummy variable
was created and used in the adjustments. Only
for father’s social class was there a considerable
number of missing values. Cronbach’s á was
calculated to compare the reliability of responses to the same question on frequency of
milk consumption five years apart.
Table 2 Twenty five year relative rates of mortality by self reported milk consumption at
baseline (in three categories) in 5765 men from the Collaborative study
Pints per day (1 pint = 0.568 litres)
none
All cause
Number of deaths
1194
Age adjusted relative rate
1
Fully adjusted relative rate†
1
Cardiovascular disease (390–459)
Number of deaths
607
Age adjusted relative rate
1
Fully adjusted relative rate†
1
Coronary heart disease
Number of deaths
446
Age adjusted relative rate
1
Fully adjusted relative rate†
1
Stroke
Number of deaths
98
Age adjusted relative rate
1
Fully adjusted relative rate†
1
Lung cancer
Number of deaths
140
Age adjusted relative rate
1
Fully adjusted relative rate‡
1
Other cancer
Number of deaths
230
Age adjusted relative rate
1
Fully adjusted relative rate‡
1
Other
Number of deaths
280
Age adjusted relative rate
1
Fully adjusted relative rate‡
1
one
> than one
Trend*
1108
0.85 (0.78, 0.92)
0.90 (0.83, 0.97)
48
0.78 (0.58, 1.04)
0.81 (0.61, 1.09)
p=0.0001
p=0.005
586
0.89 (0.79, 1.00)
0.93 (0.83, 1.04)
19
0.61 (0.39, 0.97)
0.64 (0.40, 1.00)
p=0.009
p=0.05
431
0.89 (0.78, 1.01)
0.92 (0.81, 1.06)
15
0.65 (0.39, 1.08)
0.68 (0.40, 1.13)
p=0.025
p=0.11
94
0.92 (0.69, 1.22)
0.93 (0.70, 1.24)
4
0.86 (0.32, 2.34)
0.84 (0.31, 2.30)
p=0.52
p=0.58
119
0.77 (0.61, 0.99)
0.84 (0.66, 1.08)
7
0.95 (0.44, 2.03)
0.94 (0.44, 2.02)
p=0.07
p=0.22
207
0.82 (0.68, 0.98)
0.83 (0.69, 1.01)
11
0.91 (0.50, 1.66)
0.88 (0.48, 1.62)
p=0.05
p=0.08
257
0.84 (0.71, 0.99)
0.92 (0.77, 1.09)
11
0.76 (0.42, 1.39)
0.84 (0.46, 1.54)
p=0.035
p=0.28
†Over the groups. †Adjusted for age, smoking, diastolic blood pressure, cholesterol, body mass
index, adjusted FEV1, social class, father’s social class, education, deprivation category, siblings,
car user, angina, ECG ischaemia, bronchitis and alcohol consumption. ‡Adjusted for age, smoking, body mass index, adjusted FEV1, social class, father’s social class, education, deprivation category, siblings, car user, bronchitis and alcohol consumption.
of a pint a day (< 0.189 litres/day) were
allocated to the category called “none”. Men
who drank more than a third of a pint and less
than one and a third pint (> 0.189 and < 0.757
litres/day) were allocated to the category “one
pint per day”. Men who drank more than one
and a third pints (> 0.757 litres/day) a day were
allocated to the category “more than one pint
per day”.
In 1977 about half of the cohort (2686)
returned for a repeat screening that involved
identical data collection to the initial screening.
Mortality over a 25 year follow up period has
been ascertained from flagging at the National
www.jech.com
Results
Some 45.8% of the men reported drinking less
than a third of a pint a day and 51.6% reported
drinking more than a third of a pint a day and
less than one and a third pints day. Only 2.6%
reported drinking over one and a third pints
per day. The characteristics of diVerent groups
of milk drinkers are shown in table 1. Non-milk
drinkers tended to be shorter, older and of
lower socioeconomic position and were more
likely to be current cigarette smokers, to drink
more alcohol and to have worse lung function
than milk drinkers. There was little diVerence
in blood pressure, cholesterol concentration,
triglyceride concentration, body mass index
and prevalence of ECG ischaemia between the
milk consumption groups.
Over the 25 year follow up period 2350 men
died, 892 of CHD, 196 of stroke, 266 of lung
cancer, 448 of other cancers and 548 of other
causes. The association between reported milk
consumption and mortality is shown in table 2.
Milk consumption was inversely associated
with all cause, cardiovascular, coronary heart
disease, non-lung cancer and other mortality.
As milk consumption was associated with a
more favourable profile of socioeconomic and
behavioural risk factors for mortality the
relative rates were adjusted for a comprehensive range of relevant potential confounding
factors. These adjustments attenuated slightly
the apparent protective eVect of milk consumption but the associations with all cause
mortality and cardiovascular mortality remained statistically significant at conventional
levels. The analyses were repeated splitting the
follow up period into deaths in the first 10 years
and deaths in the next 15 years. The results
were essentially unchanged for all cause,
cardiovascular and coronary mortality (data
not shown).
Cronbach’s á was calculated for the 2686
men who were screened twice, on average five
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381
Milk, coronary heart disease and mortality
years apart. This yielded a value of 0.59, representing a reasonable level of stability in
reported milk consumption.
Discussion
In this prospective study of Scottish working
men we have found no evidence that regular
consumers of milk are at increased risk of death
from heart disease or death from all causes. In
fact the age adjusted risk of mortality from all
causes and mortality from cardiovascular
disease was lower in those drinking between
one third and one and a third pints a day.
Though adjustment attenuated the relative risk
slightly it remained statistically significant for
deaths from all causes. The risk of death from
stroke was also reduced in regular milk
drinkers, though this reduction was not statistically significant and the confidence intervals
were wide.
It is likely that there is measurement error in
our assessment of usual milk consumption,
which was based on a single question about
milk drunk. The question did not ask men
about milk used in food preparation. Neither
did it ask men about intake of skimmed or
semi-skimmed milk though data from the British National Food Survey suggest that consumption of reduced fat milks was unusual in
the 1970s. The reasonable agreement between
repeat measures some years apart suggests that
this question was reproducible. Any measurement error associated with our measure of milk
consumption will have reduced our ability to
detect any real milk mortality associations.
Such measurement error is random and
though it might explain a failure to find an
adverse association with coronary death or
death from all causes in regular milk drinkers it
is unlikely to explain the apparent protective
association observed.
Confounding is a possible alternative explanation for the associations we have observed as
men who consume milk regularly may be
healthier or live healthier lives. The observations that regular milk consumers have better
risk profiles and that regular milk consumption
is associated with reduced risk of death from a
number of diVerent causes (both coronary
heart disease and cancers unrelated to smoking) support this notion. However, adjustment
for a large number of potential confounding
variables results in only modest attenuation of
the observed associations. Though we cannot
discount confounding as an explanation for
these findings it seems unlikely that residual
confounding is masking a markedly increased
risk of coronary death, or death from all causes,
in regular milk drinkers.
If regular milk consumption is not associated
with increased risk of death and particularly
coronary death (as predicted by the classic
diet-heart hypothesis) why might this be? One
possible explanation is that milk does not raise
serum cholesterol (despite its high saturated fat
content). Observations that the Maasai (a
semi-nomadic people living in East Africa) who
consume large quantities of milk have low
serum cholesterol concentrations led to speculation that milk might contain a cholesterol
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KEY POINTS
x In the past milk consumption was encouraged. More recently it has been
discouraged because of concerns about
its fat content
x We found no evidence that milk consumption was associated with increased
risk of coronary death or death from all
causes.
x Milk drinkers were healthier in several
respects. Residual confounding may explain the failure to observe increased
mortality in milk drinkers.
lowering factor or factors. Further studies in
the Maasai, however, suggest that their calorie
and milk intake were overestimated.14 Some
trials of increased milk intake in free living
humans have reported reduced serum cholesterol concentrations,15 but controlled feeding
studies, despite their small size, seem to
confirm that increased milk intake does indeed
increase serum cholesterol concentrations.16 17
Though milk contains other factors that may
increase coronary risk, such as lactose18 it also
contains some that may reduce coronary heart
disease risk, such as calcium.19 Also if milk
consumption in adulthood is associated with
milk consumption in childhood, this might
explain the association. Increased milk in
childhood leads to increased growth20 and thus
increased height. And increased leg length in
childhood and height in adulthood is associated with reduced coronary and all cause mortality.21 22
A necropsy study showed a high prevalence
of coronary hear disease in peptic ulcer patients
treated with a milk diet in the UK and the
USA.23 In the UK arm of the study 18% of
necropsied ulcer patients on a milk diet had
evidence of myocardial infarction compared
with 3% of necropsied ulcer patients not given
a milk diet (p<0.01).23 A case-control study of
women in Italy reported a modest (nonsignificant) reduction in risk of myocardial infarction with increased milk consumption—an
odds ratio of 0.9 in women drinking milk daily
compared with those drinking milk weekly.24
We are aware of seven prospective studies
that have examined the association between
milk consumption and coronary, cerebrovascular or all cause mortality. In a cohort study of
over 25 000 Seventh Day Adventists the
relative risk of coronary death was 0.94
(p<0.05) in men drinking two glasses a day
versus none but for women the relative risk was
1.11 (and not statistically significant).25 In the
Caerphilly cohort study there was a striking
inverse association between milk consumption
and coronary hear disease risk.26 In the 2818
men the unadjusted relative risk of major
ischaemic disease was 0.12 (95% CI 0.03 to
0.53) for men drinking one or more pints a day
compared with those drinking none.26 Data
from the British Regional Heart study suggested that the apparent protective eVect
observed in the Caerphilly study might be a
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382
Ness, Davey Smith, Hart
result of men with existing coronary heart disease reducing their milk intake because of their
illness, thus generating an association between
milk intake and future coronary events.27 It was
also suggested that confounding by socioeconomic position, cigarette smoking and other
coronary heart disease risk factors might have
accentuated the association between milk consumption and coronary heart disease incidence. Nevertheless, even after adjustment the
relative risk of fatal and non-fatal cardiovascular disease among the 7735 men in the British Regional Heart Study was 0.88 for men
who drank milk and had milk on their cereal
compared with those who did not.27 The Basel
study of 2974 male employees of three
pharmaceutical companies after eight years
reported that: “Milk consumption and coronary atherosclerosis at autopsy (1980 mortality
follow-up) shows a trend for an inverse
correlation (p=0.12).”28 In the Honolulu Heart
Study milk consumption was associated with
reduced risk of thromboembolic stroke—in
3150 men of Japanese ancestry who reported
drinking 16 oz of milk per day had half the
stroke risk of non-milk drinkers.29 Temporal
analyses from Japan have also shown that
increased milk consumption is associated with
decreased stroke mortality.30 In a study of over
10 000 UK vegetarians the death rate ratio for
deaths from all causes was reduced in those
who drank more than half a pint day compared
with those who drank less than half a pint a
day: 87 (95% CI 68 to113). And in those that
drank half a pint a day the death rate ratio
compared with those that drank less than half a
pint day was 70 (95%CI 55 to 88). The death
rate ratio for ischaemic heart disease was 150
(95% CI 81 to 278) in those drinking more
than half a pint a day but 76 (95% CI 40 to
143) for those drinking half a pint a day.31
Finally, in a cohort of over 34 000 middle aged
Iowa women the adjusted risk of coronary
death in those in the top quartile of consumption of dairy products (excluding butter) versus
the lowest quartile was 0.94 (95% CI 0.66 to
1.35, p for trend =0.64).32
So in summary we have found no evidence
that men who reported regular consumption of
milk were at increased risk of death from
coronary heart disease, or death from all
causes. While the modest protective associations we observed for deaths from all causes
and deaths from coronary heart disease could
be explained by residual confounding by
dietary or non-dietary exposures our data do
not support the notion that regular consumption of milk is hazardous to health.
2
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28
29
Victor Hawthorne was responsible for the original screening and
we thank him for continuing interest. Charles Gillis, David Hole
and Pauline MacKinnon are also thanked for their support.
Funding: this study was provided with funding by a grant from
the NHS Management Executive Cardiovascular Disease and
Stroke Research and Development Initiative.
Conflicts of interest: none.
1 Milk Nutrition Committee. Milk and nutrition. New
experiments reported to the milk nutrition committee. Part II the
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